When half a dozen guidelines from extremely evidence based “Esteemed cardiac societies” decide to confront an Incomprehensive cardiologist , there is no other way , but to create a personalised i-Guidelines on STEMI !

Conquering left main disease is considered as crowning glory for the Interventional cardiologists. For over three decades , CABG has remained the undisputed modality which is being challenged today. Fortunately, the Incidence of true isolated left main disease is low .(If Medina bifurcation subset is excluded)

With growing expertise , advanced hardware and Imaging ( like a 360 degree OCT fly through view ) one can virtually sit inside the left main and complete a PCI .

Still , coronary care is much . . . much . . . more than a technology in transit !

Most importantly, these complex PCIs require rigorous maintenance protocol with meticulous platelet knockout drugs , patient compliance and the genetic fate of drug efficacy . (Clopidogrel has since entered the final laps of inefficiency while Ticagrelor has some more time I guess !)

What is the current thinking about unprotected left main PCI ? Let us know it from real life experts !

Some of us also suffer from a knowledge gap and tend to think Bifurcation lesions and left main disease are two distinct entities .The fact of the matter is , significant subset of bifurcation lesions are Indeed either left main equivalents or true left mains ( Medina 1,1,1 would constitute > 50 % all bifurc lesions ) If you include Invisible left main lesions in Medina ( 0,1,1 or 0,0,1 ) detected by IVUS/OCT it might reach easily cross 90% (Scientific guess !) Does that mean we have to think CABG even for all complex bifurcation lesions ? and reserve left main disease for isolated discrete mid shaft or ostial left main ?

Final message

My observation (Sincere to my limited conscience !) at least in this part of the world is : Left main Interventions are “perceived as pride” and its more related to “show of expertise”and is little to do with patient outcome.Unfortunately , cardiologists should not be blamed for it in isolation as the studies they follow are conflicted.

Forget SYNTAX/PRECOMBAT trials, the two famous studies EXCEL (Favor PCI) and NOBLE were published in 2016 made our life tough .One suggested PCI is acceptable /on par with CABG, while the other one put CABG superior , ensuring clarity replaced with confusion ! When we have a dispute , logic would suggest we should fall back on the status quo ie “CABG is superior” unless proved convincingly. Many sections of cardiology society failed to appreciate this.

Post PCI thoughts

*It may not be that hard to do a complex PCI . But, it’s never easier to understand current cardiology literature that is supposed to raise our intellect , which has a direct relevance to patient welfare. Note, many crucial , high stake studies tend to play academic deceit games with linguistic and statistical hyperboles like Non Inferior , likely superiority , Never inferior , near equipoise , regression of hazards, virtual follow-up in real vs trial world etc , etc !

I can only hope for a better scientific world !

Reference

Which is the best option for left main disease PCI or CABG ? Journal of Individual wisdom and evidence based conscience : Volume 1 Chapter 1- Coronary Intellect : Pages 0 to ∞ Jan 2018.

We know, The Mysterious Alibaba cave opens with a voice password . . . legend tell us it had unlimited hidden treasures. It would appear , CTOs mimic the cave in several ways. What is inside ? Should we open it ? Can we come out safely ? Do we have any magical password in cath lab to get across the complex tissue boulders ?, every cardiologist would love to have one !

Dear CTO,Open Sesame . . . I have come with all the wires you love ! Please let me in !

Indication

“CTOs are never an emergency . . .but please realise we can very easily create one while resuscitating a dead snake !

Don’t think hard on evidence , then , you may not do a single case of CTO in your life .Forget all those pessimistic trials like OAT,COAT, etc and the recent ones DECISION-CTO. Ignore all guidelines. Ask your patient, and his insurance company , if they are willing , reserve the cath lab and get ready.

Pre-procedure planning

Spend at least a hour to analyse the CTO Imagery one day prior and create n action plan.

Keep knowledgeable staff for assisting , but never ask for fellow colleagues help because it hurts our ego ! Cardiac surgeon’s back up is a welcome addition even if it’s on paper.

If possible , try to ask the patient genuinely ,what is his symptom at least once ! before starting the procedure.

Timing of the procedure.

Don’t post a CTO patient either on a busy Monday morning or lazy Friday afternoon.

Hardware Inventory

The wires ,catheters, the balloons form the essential tool box .There is more than a handful of coronary automobile companies manufacture this .It is all about metallurgy , knowledge of wires, catheters , and tip thickness, (Bullet shaped as in Asahi ) , slipping , hydrophophic or philic, polymer coating , trackability, pushability , memory etc etc.

Guide wire tip morphology is as Important as the Lesion characteristics !

Analysis of the lesion (Probably most important)

Unlike conventional PCI we have no initial target.We need to poke first and find the target next ! Distal vessel status is most important ( Careful review of retrograde filling through collaterals could give more information than CT angiograms .Calcification, diffuse disease can be a real hurdle)

Lesion morphology

Softness of lesion has to be felt (Requires good wire which has sensor (Paccinian corpuscles and Merckle disc ideal ?) I guess the cortical tactile feel is as vital as the intervention expertise .I know at least one diabetic colleague of mine who finds it difficult to cross a CTO and admits he never found it easy to feel the lesion through the wires . Autonomic dysfunction ?)

Operator expertise

(Note: These are like reading swimming guidelines , you can’t learn in the shores reading books ! you have to plunge !)

Many techniques are proposed .Sequential approach (Ironically experts are licensed to use specialized wired wires directly .Beginners are advised to go with non specialized hardware and escalate step by step) Some centers are blessed with new age weapons like cross Boss and sting ray that confront the lesions in multiple frontiers. (Carpet bombing?)

CTO playground. : Its essentially a coronary contact sport with expert septal surfing , tunnelling, knuckling , kneeling , bending . Of course , It can end up in a gratifying win in few , still most of us tend to play this game without a goal (post !)

They are basically about poking the head of the lesion and trying to cross an occluded vessel millimeter by mm towards the presumed distal vessel in an Imaginary trajectory. Proximal cap, central core ,the blind tunnel , distal capsule and exit points each must be successfully conquered.

CTO crossing is the ultimate capacity of the operator to realise and feel the position of the wires in true lumen and their confidence levels in their conviction!

Multiple wires up to three are used some times to poke the lesion two of them are used to shut the false tracks and the other one is expected to enter the true lumen (Looks too good on theory !) . These are referred to in as many terms like parallel wire see-saw , CART ,Reverse CART etc .Retrograde techniques do help us but has no magic solutions.The lumen contrast , guide wire tip movement and its side branch entry would help.

Tacking complication :Always anticipate , it’s not negative mind set to look for it !

Keep pericardiocentesis kit , covered stents , micro snares and other retrieval devices ready in cart. Your support staff should be well versed with what is happening around them. Some of the dye leaks and stains are safe .They imply minor perforations that form sealed hematomas (The plane of perforations also matters. myocardial (ab-pericardial ) leaks are well tolerated .Distal perforations are also safe as long as CTO is not opened ) Online echocardiography should be readily available to monitor pericardial space leak.

When bleed into pericardial space is life threatening , A comical, but life saving option is to close the artery and restore the CTO its original state and come out of the lab quietly !

Newer Imaging guidance : Can be useful , still may not matter much when considering the interventional acumen .

CTO PCI : Time as therapeutic end point.

CTO is not an endless game with out time frame .In my opinion it shouldn’t cross 45 minutes each as in a soccer game with a brief strategic time out and of course with liberal use of ,yellow and red cards

Future directions

Japanese are the ones who pioneered CTO Interventions . We expect more Innovations ! Is it the forward looking IVUS ? It is akin to tunneling for underground metro train with GPS guiding .If you can mark the proximal and distal points , rest will be be taken care by mortised self tunneling catheters from Robotic arms steered by sophisticated algorithms.

Final message

CTO PCI remains a real Interventional challenge. We are often double blinded in both directions (antegrade as well as retrograde ). Needs much effort ,time, hardware and most importantly a non fatigued mind and body. The benefits we get may vary between gratifying to outright mediocre .Of course , it surely satisfies operator ego and express pride and courage !

Is crossing and stenting a CTO synonymous with true success ?

Yes it is , for the cardiologist and the hospital . . . I’m not sure about it for the patient !

In this sense , CTOs mimic the mysterious Alibaba cave that tempts us with Imaginary treasures but can trap us with a wrong password !

Post-Ample

* Who should CTO PCI ?

I have seen young , enthusiastic cardiologists with Immature support staff attempting CTO in remote sub- urban settings ! Though patience and expertise are essential ingredients, some amount of organised training and hardwares make CTO PCI safe and effective. Enthusiasm and affordability alone can’t be an Indication for this complex set of coronary lesions.

Reference

I still wonder why this vital paper was never published , it was just presented in the Annual ACC conference March 2017

Cardiologists at confused cross roads !

Perils of limited Intellect & Infinite greed

When not so appropriately trained cardiologists do Inappropriate things “use becomes misuse” . . . then, it won’t take much time for science to become total abuse. That’s what happened with the murky world of coronary stents.No surprise,it’s time to firefight the healers instead of the disease !

Now ,Comes the ORBITA study . Yes , it looks like a God sent path breaking trial that spits some harsh truths not only in cardiology, but also in behavioral ethics .Let us not work over time and hunt for any non-existing loop holes in ORBITA. Even if it has few, it can be condoned for sure as we have essentially lived out of flawed science for too long Injuring many Innocent hearts !

Yes , its enforced premature funeral times for a wonderful technology !

Primary PCI (pPCI) is a glorious revascularization strategy for STEMI practiced for over 2 decades but still has not proved its perceived mettle convincingly as a large population based strategy. In the mean time, the utility value of thrombolysis was systematically (Intentionally too! ) downgraded in the minds of both academic and public mind.

Truth can’t be buried for long. Series of revelations are coming up restoring the superiority of early thrombolysis over pPCI even in PCI capable centers.

In 2013, the high Impact STREAM trial argued for pharmacoinvasive approach within 3 hrs as it was at equipoise with a pPCI. Now, EARLY -MYO from China vouch for pharmaco- Invasive approach till 6 hours. (Just published in Circulation September 2017 )

I think we need to wait for some more time , for another prevailing falsehood that need to be busted ,(Looking out for some straight thinking new generation cardiologist to do it !)

What is that ?

Many of us have misunderstood(rather made to !) that pharmaco Invasive has a defined therapeutic endpoint ie taming & stenting the IRA . This is absolute ignorance happening even in state of the art centres ,ironically this beleaguered concept is backed by peer-reviewed papers from premier journals. The fact of the matter is , If thrombolysis is stunningly successful (Which at the least happens in 50 % ) one can stop with that , it’s also a therapeutic endpoint at least for time being .

Is coronary angiogram a baseline test like ECG ?

That’s what current cardiologists with cutting edge knowledge seem to believe ! Do you agree ! I am sure I’m not !

Patients with STEMI who had successful thrombolysis who had an apparently uncomplicated course (Assessed by strict clinical ECG, ECHO criteria) need not go for coronary angiogram in the immediate future.In fact some good guidelines strongly argue for it and call it as Ischemia driven PCI ! but very few seem to respect that concept.)This will not only contain the cost and ensure the vast majority of Inappropriate ( scientific quackery) coronary plumping activity in human race.

Searching for an elusive data ! Can some one help ?

I have been searching for data , from all those major pharmaco invasive studies (Which is not being reported /shared or analysed )

How many patients in the “success cohort” after thrombolysis who subsequently land up with urgent PCI related complications when trying to stent an already reperfused IRA or while tackling coexisting Innocent or non-innocent non IRA lesions ?

* Complications and adverse events may be acceptable in patients who had failed thrombolysis or who are unstable but even minor adverse events are forbidden in patient with a truly successful and asymptomatic patient.

Final message

So called scientific facts have very short half life ! for the simple reason they are let loose in human domain prematurely !

Professional competence is defined as doing things, always in the Interest of patients. It’s generally believed small hospitals are not competent enough to treat cardiac emergencies . . .Do you agree with that ? No, Its largely a myth . Do you know there is a absolute lack of proficiency threatening to plague our country’s coronary care system. ? It’s the professional Incompetence by the space age, star hospitals (mis)managed by masters of the noble business. None (am I right ?) of this hospitals either monitor or publish the outcome of their treatment.

Backed by pseudo scientific data , amplified by unrealistic expectations of ill Informed patients , some hospitals are avoiding Initial emergency treatment of acute MI , instead they waste time ( load DAPT ofcourse !) in securing the finance for the costly Invasive procedures or refer them out of their premises if they can’t afford for it.In the ensuing emotional and financial melee many of the ill-fated patients lose vital time window of thrombolysis as well ! and carry risk of fatality or damaged myocardium.

Every stake holder in the current coronary care system simply assume the enforced modality must be far superior because they administer the most modern and costly treatment suggested by few high intensity cared clinical trials originating from west. The wisemen who run the corporate hospitals never realise medical competence and outcome is not entirely defined by science. Their primitive cognition wouldn’t allow to think beyond business equations either.

Please believe me, time and again, I have witnessed patients reaching Government hospitals after being shunned away by big (Some times even medium sized ) hospitals who boast themself only as PCI enabled care. Even if they want to lyse they stock only the Tenekteplace .

I think tragedy is a lesser word to describe the scenario , where a distressed family is trying to arrange for a Rs30,000 shot of Tenekteplace when thirty times cheaper still equally efficacious (Rs 1000 Streptokinase) is concealed from their visibility .The Govt should urgently look into instances of large private hospitals avoiding Govt insurance scheme patients even in cardiac emergencies ! To label our poor patients as unaffordable ones is a outright misnomer, rather its the rich hospitals that are “not affordable” to lose profit and treat our countrymen , in a cost effective manner is the reality !

Who is Poor ? You decide.

Two forbidden things in coronary care

1.Cajoling and manoeuvring a distressed family for a primary PCI as a routine treatment hyping its beneficial effect and underplaying the true advantages of thrombolysis in largely technical jargons is the current norm in most coronary care units.

2.Another issue is , after confused confabulations with the duty medical officer, if a rare patient family choose the option of thrombolysis , comes the next googly*. Many noble minded hospitals do not stock the low-cost and equally efficacious thrombolytic agent and offering only the costly option to the anxious families when the myocardium is on fire.

Hospitals that practice these two coronary protocols need to be shamed and labeled as “Coronary Incompetent ” In spite of having 24/7 cath labs. (Realise , they are just like any remote rural hospitals , at least the later can’t be faulted as they don’t withhold a reperfusion strategy !)

Final message

I think , mindless proliferation of cath lab based cardiac care , which follow this theme , ie “Thrombolysis incapable but PCI capable “ are biggest threat to coronary care in our country ! For the best coronary care for any country ,what we need is efficient prehospital thrombolysis team .We have conveniently forgotten the great study of CAPTIM wherein the ambulance drivers replicated the same effect of primary PCI performed by highly trained cardiologists in modern labs.

In India, primary health centers which is within few km reach of entire population can be designated as static ambulance equivalents with basic resuscitation facility . If a multipurpose health worker can be trained to lyse, with remote supervision that will accomplish 90 % of what the cathlab guys can achieve ! Selective shifting is suffice.

Postample : Ofcourse, not doing pPCI for high risk or complicated STEMI is unscientific and we need to have proper consenting and referring frame-work for such patients.

Counter point : One of my colleagues asked me ? Why do I enjoy attacking the established scientific practices ? May be I have a problem , yes, but I think in a true medical democracy we have right to debate anything , absolute truth is a ongoing journey !

*Googly: An unplayable ball delivered to a batsman in the game of cricket.

CABG is always done with intention of complete revasularisation for all significant lesions. Comprehensive multivessel PCI though feasible is not practiced widely.Considering the diffuse nature of CAD no treatment is complete except probably intensive medical management.

As of now , addressing only one (or two ) critical lesions in a triple vessel disease by PCI though appear attractive and logical is considered unscientific.Guidelines are not clear in answering the issue.

In a triple vessel disease with a critical LAD lesion,

Shall we do PCI for LAD and medical management for lesions in RCA or LCX ?

How about this coronary wisdom “While medical therapy can take care of less tighter lesions , only critical lesions need catheter based Intervention”

In fact, in STEMI setting we do apply this logic of targeting one lesion (IRA) at a time. Why not in chronic coronary setting ? There are significant pros and cons for this approach.While, most 0f us will go with the logical herd,an unique paper by Mineok asks us to think again(American Heart Journal, 2016-09-01, 157-165)

How do you define the completeness of revascularization? Is it not emprical ?

We know medical management has well documented advantages in chronic CAD. while multivessel stenting has its own hazards.Hence limiting the time spent within the coronary artery and reducing total stent length should be one of our important goals.

A mini quiz . . .

How often you have left a fairly significant lesion (attending only the critical lesions ) in your practice ?

What do you think will happen to those non critical lesions in the long run ?

Do you believe earnestly drugs can take care of these lesions ?

Forget the science . Whats your experience and gut feeling ?

Do you agree , even surgeons do not always do a complete revascularisation either intentionally or for technical reasons ?

I would say , the science of coronary revascularisation in chronic CAD is stranded at a confused cross road even after three decades of aggressively grown interventional cardiology .At any given point of time medical management can give a tough fight to catheter based intervention in most stable IHD.

Hybrid therapy doesn’t always mean combination of PCI and CABG. Judicious mix of PCI and medical therapy is also a hybrid modality that can bring CAD burden effectively in a meaningful fashion with less metal load. If you can convert a critical triple vessel disease to non critical DVD or SVD with a single stent it should be welcomed without prejudice.

With a section of cardiac scientists are in hot pursuit for a completely bi0reabsorbable stents , let us adopt this “Minimalistic PCI approach” in multivessel CAD, till the time we reach the “dream the end point” of modern coronary care , ie to get rid of stent altogether by biological cure for atherosclerosis.